Excel B.738 Serious incident at EGCC

[The AvgasDinosaur]

Dear All,
Found this, thought it might be worthy of your thoughts
http://www.aaib.dft.gov.uk/sites/aaib/publications/formal_reports/3_2006_g_xlag.cfm
Be lucky
David

[Accident Prawn]

The crew of G-XLAG did not realise that Runway 06L was operating at reduced length due to work-in-progress at its far end, until their aircraft had accelerated to a speed approaching the rotate speed (VR), despite:

• Being in possession of a NOTAM concerning the work-in-progress

• The ATIS broadcast relating to the work-in-progress

• ATC passing information on the takeoff distance available

WHAT???????? :ugh: :ugh: :ugh:

[Mercenary Pilot]

You can see the links connecting in this one :bored:

[cargo boy]

Watch the media miss the point in this report. I think it is summarised beautifully on page 30 (section 2.2) of the report:

"It was therefore apparent that senior members of the airport’s operations team did not have an adequate understanding of aircraft operations and the planning requirements of other airport departments."

Take the whole shabang one step up the corporate ladder and you can see the moneygrabbing ideas behind employing graduates from the Harvard School of Business Management whose comprehension of airfield operations is in doubt but will think of profits first. I'd bet a pound to a penny that the management team would pull out all the stops if one of their precious retail areas was out of commission for a week or so.

So, we have Wythenshaw Municipal Airport, one of the busiest shopping centres in the UK, with a management team that is shown in this report to be barely able to organise a p!ssup in a brewery when it comes to non-direct profit areas of running their operation with regards to operational requirements involving safety. Some of us wonder why it is taking so long to keep moving that darned hole around the ramp and taxiways. Well, now you have your answer. :rolleyes:

The Xcel crew were a bit too relaxed about their operation and no doubt will have learnt a valuable lesson from all this when it comes to what has to be done in a proper briefing session. At the same time, thanks to their mistakes, the real side of modern airport/retail operations has been exposed. I just hope the media are able to extract the relevant parts of the report and show the rest of the travelling public what really is behind the yukspeak that comes from the corporate heads of these Plc's that claim safety really comes before profits. :hmm:

[Duckbill Platypus]

Hmm, it would seem there is some kind of problem with the management in ATC as well. I see it mentioned at least twice in the report that 'The comments by the deputy supervisor on duty at the time of the incident suggested a feeling that the controllers believed their only safe option was to refuse to operate aircraft on the reduced length runway at all, but he said to do so would have been seen as dissention, with possible disciplinary consequences.'

So we have controllers who are very "uncomfortable" with aircraft taking off towards vehicles on the runway even though the declared distances have been NOTAMed (inadequately) yet felt unable to apply their skills and experience because some management bods in their ivory towers would have most likely started disciplinary procedures against them. Apparently, their training and skills are irrelevant when it comes to anything that may affect their managements negotiations with the airport to renew the contract and if it is going to affect anything that hits 'profits' it is likely they'll be accused of "dissention".

I don't know about any of you who have read this report but I'm flabbergasted at the glaringly obvious signs of modern management techniques, both in the MAplc and NATS, that show such poor decision making and what appears to be cost saving to the point of lining up all the holes in the Swiss cheese. This was, according to the report, a disaster waiting to happen and was only prevented by sheer good luck.

[brain fade]

Just my tuppenceworth

Surely operating with trucks on the runway is a total no-no.

Notam'd or not. Reduced TORA/ TODa promulgated or not.

For example. Tyre burst at just below V1. Ok I know some operators reccomend to continue but hard to diagnose in an instant. Will it stop before the trucks or not? Who knows?

Also crews make mistakes or may mishandle the a/c or mess up the performance calcs. Just too many things could happen causing a dreadful pile up.

If ever there was an accident waiting to happen this is it!

Damn lucky they never killed a bunch of folk. Why did no ATCers speak up on the day for ***** sake?

This operation seems to fly in the face of common sense.

[The AvgasDinosaur]

You can see the links connecting in this one :bored:
More holes than cheese to line up here methinks
Be lucky
David

[Ranger 1]

I would have thought they would have arranged the Work to have been done at night & closed the Runway & used the other one.
But there again some these highly qualified individuals who live in the virtual world, always seem to know best when it comes to earning Brownie points :ugh:

[Skipness One Echo]

What a shame they don't have another runway.......WAIT a minute

[Niguel_Normale]

Accident Prawn

What's it like to be perfect?

[Two's in]

The report indicates a marked reluctance by qualified personnel, both in ATC and Airfield Management, to formally declare that they were unhappy with the operations being conducted. The real question is what is the culture of risk awareness and reporting at Manchester, and why was there a reluctance to make such a report? It's easy to blame "management pressure", but what kind of person would risk sending a couple of hundred people to a very unpleasant demise before they would run up a red flag with management over something they felt was unsafe? The pilots were not blameless in this (for the obvious acts of ommission), but they are almost incidental to the underlying cause of severe and multiple cases of poor judgement and lack of integrity within the Airfield Operations staff. Such a widespread problem is historically linked to flawed leadership at a higher level.

[spinnaker]

A short time after this incident I was commander of a 737 and informed by tower, as we taxied out at MAN that our TO run was reduced to xxxx meters (I had noted this in the NOTAM) I asked the FO to politley inform atc that we could not accept reduced TO run and request the other runway as stated in our clearances prior to push-back. The responce from tower was nothing short of snotty, telling us that we would have to take a delay if I was insistant on using the other runway. Well let me put it this way, I would rather take a delay, than smash an 80 tonne fully laden jet into the hedge at the far end of the runway. It really is that simple. It's long overdue for safety to be put first, Chief execs to trust their Captains and crew, and commanders to bloody well command!

[armada]

spinnaker :D

[Avman]

:D Well said Spinnaker. You're the kind of guy I want sitting up front when I'm flying. The same principle should apply to other frontline personnel in the aviation industry including ATC.

[WHBM]

Well I have read all the detail.

Is it now reasonable to ask the Airport Manager to consider their position ?

[Curious Pax]

It might be valid to ask that the appropriate managers consider their position, but given that this all happened 3 years ago are many of them still in situ?

Am I the only one to think that 3 years to produce the report seems a little excessive given that (thankfully) things weren't complicated by having a shredded aircraft to deal with. Thoroughness and attention to detail are commendable things, but there needs to be a degree of timeliness I would have thought?

[Helen49]

Sloppy operations all round imho. Safety must be managed.

H49

[Mad As A Mad Thing]

Damn lucky they never killed a bunch of folk. Why did no ATCers speak up on the day for ***** sake?

Easy to say, but what do you expect the ATCO to do? When it comes to the crunch in a situation where you have voiced your opinion to your superiors that something doesnt seem right, but you do not have the specific knowledge to prove that it is patently not right, and your concerns are rebuffed in the belief that the people responsible know better.

Remember that without the added errors of the Excel crew, this incident would not have taken place. Its easy afterwards to say that the ATCOs should have done something, but without the benefit of this incident, concerns such as these are frequently brushed aside. It's one thing to feel uncomfortable with a situation, but its another entirely to be SURE that something is downright dangerous and needs to be stopped.

What do you really think is going to happen to an ATCO who makes the lonely decision to refuse to work in a situation like this, assuming that no incident actually occurs subsequently?

Firstly he will be replaced by someone who will do the job, so nothing acheived there unless the whole ATCO contingent follows his lead.

Secondly I expect he will then have to justify to management why he refused to provide a service/obey management instructions etc, against the evidence that the basic calculations of the runway closure in this case were correct, and correctly promulgated.

In this business it's really easy to earn a reputation for being difficult or a trouble maker, just because of tendency to not unquestioningly accept everything that management do. A reputation like that (even if a result of the best possible intentions) is likely to damage anyone's career prospects, cos we all know that you can't get on unless you toe the party line. So anyone with an ounce of ambition is going to face a very real conflict of interests in this situation.

I'm not saying it's right, far from it, but I'm saying that it is the reality, or equally importantly the perceived reality of the situation from an ATCO's point of view.

[cwatters]

The importance of CRM (Cockpit Resource Management) was recognised years ago. Perhaps time for airport management and ATC to go on the course together?

[Musket90]

When an alternative full length runway is available then the runway being worked on should have been fully closed for the work to be carried out. If the single runway operation causes complications whether it be delays or environmental then the works should be planned at times when traffic schedules are light i.e during the quiet night hours.

LHR and LGW plan runway works in this way, however at single runway airports like STN it must be very difficult to plan runway closures for work when the demands of airlines require the runway to be available at all times. STN has just completed runway resurfacing when for 9 months and for 3 night a week the runway operated at reduced distance with many movements taking place without incident. It can be done if all involved take the time to identify the risks and how to mitigate against them.

Looks like MAN could learn a lot from LGW, LHR and STN when it comes to planning and carrying out runway works.

[brain fade]

Mad as a Mad thing

I take your point of course. Never pleasent to be the first to stick ones head over the parapet.

On the other hand, how wou feel, as the ATCO, if it had piled into these trucks killing all on board, while all the time you knew what was going on was a crock of sh.t but never had the guts to speak out?

I know there are always 'consequences'. For pilots and pax they can be more serious than for traffickers. (that poor Swiss guy excepted of course).

Easy after the event, mind.

[late developer]

In this business it's really easy to earn a reputation for being difficult or a trouble maker, just because of tendency to not unquestioningly accept everything that management do. A reputation like that (even if a result of the best possible intentions) is likely to damage anyone's career prospects, cos we all know that you can't get on unless you toe the party line. So anyone with an ounce of ambition is going to face a very real conflict of interests in this situation.This is the same for everyone in aviation. If you say nothing you are part of the problem and are guilty of risking people's lives in exchange for your own commercial self-preservation.

Join an effective union if you don't feel strong enough on your own to say No. Regain some strength of conviction that way, but don't hide and take the line of least resistance.

I agree Spinnaker is of the right stuff:D

[old-timer]

A very concerning thread - tip of the ice berg ? - I sincerely hope not ...but
in the real world....there but for the grace of Accountants & Directors ....angels fear to tread !

Well said Spinnaker a few posts aft,
let commanders command -

[Llademos]

STN has just completed runway resurfacing when for 9 months and for 3 night a week the runway operated at reduced distance with many movements taking place without incident. It can be done if all involved take the time to identify the risks and how to mitigate against them.
Looks like MAN could learn a lot from LGW, LHR and STN when it comes to planning and carrying out runway works.
Hear hear ... STN may have its detractors, but the notification and continuing conduct of the runway works was pretty much faultless - and finished on time too!

[Safety's No Accident]

An airline I once worked for had a poster on the wall that said:

"If you think safety's expensive?... Try having an accident !"

Wise words, imho, that should be obligatory in every Boardroom.

[Sleeve Wing]

It's long overdue for safety to be put first, Chief execs to trust their Captains and crew, and commanders to bloody well command!

Spinnaker mate, 'twas ever thus.
When I first worked for an airline, we were given a roster and an aeroplane and expected to get on with the job.
Ops. and ground staff were great, ATC were (nearly) always understanding, engineering were brilliant.
No hassle with getting from the carpark, no hassle from Security, no jobsworth from any department trying to score points.
We were allowed to get on with the job. Everybody was in it together, to get on with it and hopefully make a profit........and we felt good if the day went well. - tired too, but not sh*gged out.

Sure, we had to have the right answers if it went pear-shaped but overall we were allowed to run "our bit".

The point is that EVERYONE,.... crews, airport staff, catering, fuellers, EVERYONE, ... knew what they had to do, without fear of petty reprisal; no looking over the shoulder. The captain was the coordinator.

It's all changed , hasn't it? .....................Progress ??

[Nubboy]

"Remember that without the added errors of the Excel crew, this incident would not have taken place."

I really can't believe this comment from a colleague in a parallel profession.

This implies that you are willing to watch an unsafe operation develop, because any subsequent accident or incident will be the other guys mistake not yours.

This completely beggars belief.

Any time I'm stupid enough to get in a situation where I have to get everything absolutely right (not just at work I hasten to add), to get a successful or safe outcome, then I've already screwed up.

PEOPLE MAKE MISTAKES. We have to have slack in the system to allow for the errors we don't intend to make.

[sox6]

CAA response:
http://www.caa.co.uk/docs/33/factor200646.pdf

This part caught my eye - emphasis added:

Recommendation 2006-11
It is recommended that the Civil Aviation Authority, in conjunction with National Air Traffic Services and other air traffic service providers, jointly review the current risk analysis associated with operations from runways when at reduced length, to ensure that it remains valid.

CAA Response
The Civil Aviation Authority accepts this safety recommendation. Each Air Navigation Service Provider’s Safety Management System requires a risk assessment to be completed for every change of operational procedure.
Therefore, the Civil Aviation Authority will remind all Air Navigation Service Providers and Airport Operators, of the requirement to conduct a risk assessment prior to the introduction of operations from runways at reduced length.
The Civil Aviation Authority will also remind Air Navigation Service Providers of the need to ensure that, where they and the Airport Operator use separate safety management systems, a robust and effective interface between the two systems is established and maintained.

Is this just a lazy fudge when they don't want to object to the recommendation??

Or perhaps they want to emulate Safety's No Accident and just put some Stalinist style messages up.

[Maude Charlee]

Would this be at all connected with the current search for a new chief pilot at Excel?

[omnidirectional737]

Would this be at all connected with the current search for a new chief pilot at Excel?

No, seeing as the curent one is being made DFO.

[Adola69]

PEOPLE MAKE MISTAKES. We have to have slack in the system to allow for the errors we don't intend to make.
There was slack in the system, - apart from some probably brown (later to be disgarded )undergarments - (well I hope they were?) nothing hit anything and nobody was injured.There had been no problems with the reduced length available to other users prior to this. It is a procedure that has been used many times before without any problem but like with everytning else these days you get just one incident occuring where someone hasn't done their job properly and the whole system is called into question instead of the muppet who made the error.
There were the normal systems in place, NOTAM, ATIS Broadcast, ATC R/T input - that is a TRIPLEX system - good enough for me! :ugh: :eek:

[Daysleeper]

There had been no problems with the reduced length available to other users prior to this.

Apart from the 146, the 3 go arounds including the tristar from 600' and all the other ones that may have occured but no one reported/noticed.

Oh and the fact that the incident appears to highlight massive deficiencies in the airports safety management system and the fact that the ATC provider appeared unprepared to stand up to the owners because of commercial considerations and the ATC bods on duty were aparently unprepared to take action to protect life because they were afraid of disciplinary action. That and the crews actions makes this look like sheer luck that this was not 180+ corpses scattered over the runway.

Keep living in your rose tinted world Adola.

[Mariner9]

Only a ppl so feel free to shoot me down, but I'm surprised that such a lengthy report largely ignored the 3 G/A aircraft -surely they should have had appropriate Notams & Arrival ATIS too?